Virtual Camp SHIELD 2021 Family Application

Jacoby's Journey Group

Thank you for your interest in Jacoby's Journey Group. We look forward to you joining us. Please complete this application to register. Questions? Please contact us at 803-400-3299.
First Name
Last Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone #

Area CodePhone Number
Email
name@address.com
SMS Consent and Email

"By providing your phone number and email, you are consenting to receive SMS messages and emails from Jacoby's Shield. These messages may include information about our upcoming support groups, fundraising events, products, services, promotions, and important updates. Standard message and data rates may apply. You can opt out of receiving these messages at any time by replying 'STOP'. For more information, please refer to our Privacy Policy."
Name

First NameLast Name
Who are you are grieving?

First NameLast NameSuffix
Birthday?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearWhat is their birthday?
Date of death?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearWhat is the date of their death?
Age of the deceased?
What was their age when they died?
Relationship to you?
The Deceased was your _________
Cause of Death

0/100
Who are you are grieving?
Are there any additional loved ones that you are grieving?
Who are you are also grieving?

First NameLast NameSuffix
Birthday?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearWhat is their birthday?
Date of Death

MonthDayYear
2 digit month, 2 digit day, 4 digit yearWhat is the date of their death?
Age of the deceased?
What was their age when they died?
Relationship
The Deceased was your _______
Cause of Death

Please give the cause of death.0/100
Have you or any of your family members received professional support?
Have there been any other changes/stresses in your family's life?
IE: Divorce, illness, relocation, etc.
Is there anything else you would like us to know about how you and your family is coping with the loss?

0/200
Will you be attending our Journey Group in person or virtually
Are there any adult family members that will be attending with you?
How many?
How many other adult family members will be attending with you?
Please list all other adult family members attending Jacoby's Journey Group.
Do you have any other questions?
How did you hear about Jacoby's Journey Group?
Consent to Use of Photographic and Video Images: Jacoby's Shield may be photographing, videotaping, audiotaping or webcasting Jacoby's Shield meetings, activities, and Jacoby's Shield-sponsored events. Registration, attendance at, and/or participation at any of these events constitute an agreement by the registrant or attendee to these activities and to the use and distribution of the registrant’s or attendee’s image, likeness, or voice in photographs, videotapes, electronic reproductions, and audiotapes.
NOTE: Please be aware that registration fee is NON REFUNDABLE
Should be Empty:

Jacoby's Journey Group